**2. Dietary intake of preschool children**

Children under five years of age, who consume high-energy sugary foods and live a sedentary lifestyle, are more likely to develop type 2 diabetes and cardiovascular disease in early childhood, and this is associated with higher likelihood of disability and premature death [7]. Energy-rich, nutrient-poor, high-sugar, high-salt snacks, and sugar-sweetened beverages (SSBs) contribute to childhood obesity [5, 8]. Preschool children eat high-fat, high-fat energy-dense foods such as fries, crisps, bread, and processed foods [7]. In addition, some studies show that most children around the world eat a large amount of energy-intensive foods, saturated fats from animals, which increases the risk of overweight and obesity [9, 10]. Intake of fatty foods with high trans fats and saturated fats, high energy density foods, is associated with childhood obesity [11]. Moreover, diets high in trans fatty acids were found to increase risk of obesity and cardiovascular disease by 27% [12].

High-protein diets such as fatty lamb, beef, and fried chicken are a risk factor for childhood obesity, as high protein content stimulates insulin-releasing amino acids, resulting in weight gain and obesity [13, 14]. Most working parents and those who do not have time to cook at home buy fast foods, which are convenient and affordable, but high in calories, with unhealthy fats, sugars, salt [12].

In rural and urban areas in North West province, South Africa, the consumption of sugar and sweet beverages (SSBs) is increased among children under five years of age, thus increasing the risk of childhood obesity [15, 16]. Increased consumption of SSB leads to an increase in calories, which in turn leads to weight gain and causes children to become overweight and obese [17]. High intake of sugar beverages among children from low-income households may be related to low prices and this becomes a risk factor for childhood obesity [12]. High-sugar drinks are less filling than food and can be consumed in greater quantities, increasing the calorie intake. According to a 2014 Economic Research report, the average daily consumption of calories in the United States has increased by 459 over the past 40 years [18].

Most overweight children have been reported to eat snacks between meals, especially pastries, and few children consumed healthy snacks, such as fruit or nuts [17]. Large portions lead to high calories and a 30% increase in energy was noted when children were offered large portion sizes [18]. In addition, a study conducted in the United States showed that less children had smaller portion of food and most children ate larger portions [19]. WHO recommends that preschoolers consume a smaller proportion of nutritious food which has lower energy density as an important strategy for prevention and management of childhood obesity (**Table 1**) [6].



#### **Table 1.**

*Recommended food group portion sizes for children 2-5 years of age (Source: [6]).*
